Getting Insurance to Pay for Drug Rehab – How Health Insurance Companies Evaluate Rehab Claims

Need coverage for rehab and wondering if you qualify? Well, unfortunately, there’s no way to condense the labyrinthine legalese of a thousand care policies into one comprehensible document.

But fortunately, provided your policy covers substance abuse treatment, all you really need to understand is the concept of Medical Necessity.

If you can prove that you have a medical need for residential substance abuse treatment (rehab), your provider should accept your claim.

But how do you prove that?!

Read on for a brief explanation of medical necessity and for some examples of the kinds of behaviors and situations that should qualify you for residential substance abuse treatment coverage.

The Concept of 'Medical Necessity'

Most insurance companies approve or reject treatment based on the principles of medical necessity.

According to the American Society for Addiction Medicine (ASAM), the core components of medical necessity are:

1. The requested treatment services are required to diagnose or treat a suspected or identified illness or condition.
2. The requested treatment services are appropriate for the condition and meet the standards of good medical practice (meaning that scientific evidence proves that the requested treatment is effective for the condition).
3. The requested treatment is required for more than just the convenience of the requester or provider (meaning, for example, that though you might find it more comfortable to go away to rehab, unless you can prove that you need it for a medical reason, you will likely get coverage only for outpatient treatment).¹

Although the ASAM identifies only these three core components, most insurance companies add a fourth component to the decision-making process, namely that:

4. The requested treatment is not more costly than any other treatment that is as likely to produce an equivalent result.²
   

Examples of What Qualifies You for Rehab Coverage

You’ll likely need to read the fine print of your policy documents to know for sure, but if your contract covers substance abuse treatment then read on for some general examples of the kinds of preconditions that generally result in a claim approval for residential treatment.

You’ll probably need to meet ALL of the following criteria:

• Your withdrawal symptoms can be managed at the requested level of care (you might need hospital detox, first, for example)
• You are cognitively able to participate in a treatment program and have no other medical problems which preclude your ability to participate
• You show evidence that you want treatment and that you are motivated to work toward recovery

You’ll need to meet AT LEAST ONE (and possibly more) of the following criteria:

• The severity of your self-harm or risk taking behaviors present a serious threat to yourself or to others and these self-harm or risk taking behaviors can’t be effectively managed outside of a 24 hour facility.
• You have acute medical problems that make it difficult or impossible for you to stay abstinent outside of a residential environment
• Your substance abuse is causing severe problems in at least 2 domains of life, such as school/work, family, social relationships, physical health etc.³
  
• There is evidence that a lower level of care wouldn't help (such as previous attempts within the last 3 months at a lower level of care, like an intensive outpatient program.)
• There is evidence that unless you get residential treatment your condition is going to continue to worsen, to the point where you’ll probably need hospitalization (a more serious level of care)
• There is evidence that residential treatment should help to ameliorate symptoms⁴
• Your current living arrangements are dysfunctional and endanger your recovery progress and there are no other clinically appropriate or available living arrangements